Resp Flashcards
how common is lung cancer
3rd in the UK
types of NSCLC (80%) - other 20% is SCLC
- Adenocarcinoma (40%) (peripheral)
- SCC (20%) (central)
- Large-cell carcinoma (10%)
- Other types (10%)
what do SCLC contain
neurosecretory granules that release neuroendocrine hormones. SCLC may be responsible for various paraneoplastic syndrome
what is mesothelioma
- related to asbestos
- latent period of up to 45 years
- poor prognosis: palliative
presentation of lung cancer
- SOB
- haemoptysis
- clubbing
- cough
- recurrent pneumonia
- FLAWS
- supraclavicular LN
extrapulmonary manifestations of lung cancer
- Recurrent laryngeal nerve palsy presents with a hoarse voice = tumout pressing on RLN
- phrenic nerve palsy = due to nerve compression, causes diaphragm weakness and SOB
- SVCO = facial swelling, SOB, Pemberton’s sign
- Horner’s = ptosis, miosis, anhidrosis. Pancoast tumour
- SIADH= ectopic ADH by SCLC, hyponatraemia
- Cushing’s = ectopic ACTH by SCLC
- hypercalcaemia= ectopic PTH by SCC
- limbic encephalitis= paraneoplastic syndrome
- lambert eaton
2ww lung cancer referral criteria
- clubbing
- supraclavicular LN
- recurrent chest infection
- thrombocytosis
- chest signs
CXR cancer signs
- hilar enlargement
- peripheral opacity
- pleural effusion (unilateral)
- collapse
Ix for lung cancer
- staging CT
- PET
- bronchoscopy with EBUS
- histological
Mx of lung cancer
NSCLC
- surgery, radiotherapy, chemo
SCLC
- chemo and radiotherapy
endobronchial treatment with stents for palliative
main thoracotomy incisions
- anterolateral thoracotomy= incision around the front and side
- Axillary thoracotomy = incision in the axilla
- Posterolateral thoracotomy= incision back and side (most common)
Signs of URTI and LRTI
URTI- stridor
LRTI- wheeze
characteristic chest signs of pneumonia
- Bronchial breath sounds (harsh inspiratory and expiratory breath sounds) due to consolidation around the airways
- Focal coarse crackles caused by air passing through sputum in the airways
- Dullness to percussion due to lung tissue filled with sputum or collapsed
curb-65
Confusion
urea >7
RR >30
BP < 90/60
>65
0-1 mx at home
2: consider hospital
3: ITU
causes of pneumonia
- Streptococcus pneumoniae (most common)
- Haemophilus influenzae
- pseudomonas (CF/bronchiectasis)
- staph Aureus (CF)
- MRSA in HAP
atypical pneumonia
- legionella: air conditioning
- mycoplasma: erythema multiforme
- Coxiella burnetii: bodily fluids/animals
- chlamydia psittaci: infected birds
signs of klebsiella pneumonia
- alcoholic and diabetic
- currant jelly sputum
- affects upper lobes bilaterally
PCP features
- fungal pneumonia
- in HIV and low CD4
- dry cough, night sweats
- prohylactic co-trimoxazole if low CD4
Abx for mild CAP
5 days amox, doxy or clari
Abx for moderate/severe pneumonia
IV abx
amoxicillin and a macrolide
7-10 days
ABG for types of respiratory failure
- Type 1: normal PaCO2 and low PaO2 (1 wrong)
- Type 2: Raised PaCO2 and low PaO2 (2 wrong)
ABG raised bicarbonate
- chronic CO2 retainer.
- Kidneys produced bicarbonate to balance acidosis takes time.
- COPD patients
cause of resp alkalosis
hyperventilating
cause of metabolic acidosis
- raised lactate
- raised ketones
- increase hydrogen ions (renal failure)
- reduce bicarbonate (diarrhoea)
causes of metabolic alkalosis
- vomiting
- kidney increased activity of aldosterone increase H+ excretion (conn’s, cirrhosis, HF, diuretics)
what is ARDS
due to severe inflammatory reaction in lungs often secondary to sepsis or trauma
pathophysiology of ARDS
- Collapse of the alveoli and lung tissue (atelectasis)
- Pulmonary oedema (not related to heart failure or fluid overload)
- Decreased lung compliance (reduced lung inflation when ventilated with a given pressure)
- Fibrosis (typically after 10 days or more)
clinical signs of ARDS
- Acute respiratory distress
- Hypoxia with an inadequate response to oxygen therapy
- Bilateral infiltrates on a chest x-ray
Mx of ARDS
- resp support
- prone positioning
- fluid mx
what is end expiratory pressure
pressure that remains in airway at end of exhalation
what is PEEP
additional pressure at end of exhalation to keep lungs inflated
presents atelectasis
how is PEEP created
- head bobbing in children
- high flow NC
- NIV
- mechanical ventilation
what does high flow O2 do to dead space
deadspace washout
what is CPAP
constant pressure to maintain airway adding PEEP to those who likely to collapse e.g. OSA
what is NIV
- cycle of high and low pressure to correspond to the patient’s inspiration and expiration
obstructive lung disease
- FEV1 < 70% FVC so ratio of FEV1:FVC <70%
- obstruction blocking air from getting out quickly
- asthma: due to bronchoconstriction
- COPD due to airway and lung damage
restrictive lung disease
- FEV1 and FVC are equally reduced
- FEV1:FVC ratio greater than 70%
- FVC reduced to restriction of lung expansion + capacity
restrictive lung diseases
- Interstitial lung disease, such as idiopathic pulmonary fibrosis
- Sarcoidosis
- Obesity
- Motor neurone disease
- Scoliosis
atopic conditions
- asthma
- hayfever
- eczema
- food allergies
asthma examination findings
polyphonic expiratory wheeze
differentials for localised monophonic wheeze
- foreign body
- tumour
- mucus plug
medications that can worsen asthma
- BB
- NSAIDs
Ix for asthma
- spirometry
- reversibility with bronchodilator
- FeNO (marker of airway inflammation)
- peak flow
- direct bronchial challenge testing
moderate exacerbation of asthma
PEF 50-75%
severe exacerbation of asthma
- Peak flow 33-50%
- Respiratory rate above 25
- Heart rate above 110
- Unable to complete sentences
life threatening asthma
- Peak flow less than 33%
- O2 < 92%
- PaO2 less than 8 kPa
- Becoming tired
- Confusion or agitation
- No wheeze or silent chest
- Haemodynamic instability
mx of acute asthma
Moderate
- bronchodilator via spacer up to 10 puffs
Severe
+ prednisolone 40mg
salbutamol 5mg nebuliser
O2 to maintain 94-98%
Life threatening
- nebulised bronchodilator with ipratropium bromide
- prednisolone 40-50mg
- ABG every hour
- can give IV mag sulphate
- IV aminophylline by senior
long term management of asthma
- low dose ICS/formoterol (AIR therapy)
- low dose MART
- moderate dose MART
- check FeNO level
- trial either LTRA or LAMA in addition to moderate dose MART for 8-12 weeks
side effect of salbutamol
- hypokalaemia
- tachycardia
- lactic acidosis
mx post asthma exacerbation
- optimise long term mx
- asthma self management plan
- prednisolon 40-50mg for 5 days
- GP follow up within 2 days
what is COPD
long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema
most common organism causing infective exacerbations of COPD
haemophilus influenzae
then:
Streptococcus pneumoniae
Moraxella catarrhalis
what is chronic bronchitis
long-term symptoms of a cough and sputum production due to inflammation in the bronchi.
what is acute bronchitis
chest infection which is usually self-limiting in nature
inflammation of trachea and manjor bronchi
mx of acute bronchitis
analgesia
good fluid intake
consider doxycycline if patient has co-morbidities or very unwell
what is emphysema
damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange
presentation of COPD
- Shortness of breath
- Cough
- Sputum production
- Wheeze
- Recurrent respiratory infections, particularly in winter
- NO CLUBBING, HAEMOPTYSIS OR CHEST PAIN
MRC dyspnoea scale
- Grade 1: Breathless on strenuous exercise
- Grade 2: Breathless on walking uphill
- Grade 3: Breathlessness that slows walking on the flat
- Grade 4: Breathlessness stops them from walking > 100m on the flat
- Grade 5: Can’t leave the house due to breathlessness
severity of COPD
- Stage 1 (mild): FEV1 > 80% of predicted
- Stage 2 (moderate): FEV1 50-79% of predicted
- Stage 3 (severe): FEV1 30-49% of predicted
- Stage 4 (very severe): FEV1 less than 30% of predicted
long term mx of COPD
- stop smoking
- pneumococcal and flu vax
- pulmonary rehabiliation
mx of COPD
- SABA and ipratropium bromide
- steroids
- abx
no asthmatic/steroid responsive features
- LABA +LAMA
asthmatic/steroid responsive features
- LABA + ICS
final
- LABA, LAMA, ICS combo (trimbow)
mx of infective exacerbation of COPD
amoxicillin, clarithromycin or doxycycline
mx severe COPD
- nebulisers (SABA+IB)
- oral theophylline
- mucolytics
- prophylactix abx
- oral steroids
- NIV
- doxapram (instead of NIV)
- long term O2 therapy
indications for NIV in COPD exacerbation
- respiratory acidosis
what is cor pulmonale
right sided heart failure caused by respiratory disease
causes if cor pulmonale
- COPD
- Pulmonary embolism
- Interstitial lung disease
- Cystic fibrosis
- Primary pulmonary hypertension
sx of cor pulmonale
- SOB
- peripheral oedema
- breathless on exertion
- syncope
- chest pain
signs of cor pulmonale
- Hypoxia
- Cyanosis
- Raised JVP
- Peripheral oedema
- Parasternal heave
- Loud second heart sound
- Murmurs (e.g., pan-systolic in tricuspid regurgitation)
- Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)
Mx of cor pulmonale
- diuretics
- long term oxygen
- poor prognosis
contraindication to NIV
untreated pneumothorax
white out on Xray indications
- pneumonectomy
- pleural effusion
- consolidation
- collapse
- specific lesions e.g. tumours
fluid e.g. pulmonary oedema
white out hemithorax with Trachea pulled toward the white-out
- Pneumonectomy
- Complete lung collapse e.g. endobronchial intubation
- Pulmonary hypoplasia
white out hemithorax with Trachea central
- consolidation
- pulmonary oedema
- mesothelioma
white out hemithorax with Trachea pushed away from the white-out
- Pleural effusion
- Diaphragmatic hernia
- Large thoracic mass
Pleural effusion causes
transudate
or exudative
transudative causes of pleural effusion (< 30g/L protein)
- heart failure (most common)
- hypoalbuminaemia
- liver disease
- nephrotic syndrome
- malabsorption
- hypothyroidism
- Meigs’ syndrome
what is Meig’s syndrome
triad of:
1. benign ovarian tumour (usually a fibroma)
2. pleural effusion
3. ascites
exudative causes of pleural effusion (>30g/L protein)
- infection: pneumonia (most common), TB, subphrenic abscess
- connective tissue disease
- rheumatoid arthritis
- SLE
- neoplasia
- cancer: lung+mesothelioma
- metastases
- pancreatitis
- pulmonary embolism
- Dressler’s syndrome
- yellow nail syndrome
Light’s criteria for establishing an exudative effusion
- Pleural fluid protein / serum protein greater than 0.5
- Pleural fluid LDH / serum LDH greater than 0.6
- Pleural fluid LDH greater than 2/3 of the normal upper limit of the serum LDH
presentation of pleural effusion
- SOB
- dullness to percussion
- reduced breath sounds
- tracheal deviation away
Mx of pleural effusion
small= conservative
larger= aspiration or chest drain
what is empyema
infected pleural effusion
mx- chest drain + abx
causes of pneumothorax
- spontaneous
- trauma
- iatrogenic
- ashtma, COPD, infection
ix for pneumothorax
erect CXR
Pneumothorax mx
no/minimal sx- conservative
if sx assess for high risk characteristics:
- haemodynamic compromise
- significant hypoxia
- bilateral pneumothorax
- underlying lung disease
- ≥ 50 years of age with smoking hx
- haemothorax
conservative mx of pneumothorax
- primary spontaneous pneumothorax = review every 2-4 days as an outpatient
- secondary spontaneous pneumothorax= monitor as an inpatient
If stable, follow-up in the outpatients department in 2-4 weeks
mx of patients with high risk characterisitics and pneumothorax
- generally need chest drain
mx of low risk pt w pneumothorax
<2m = conservative
>2cm= patient priority
conservative, ambulatory device or needle aspiration/chest drain
ambulatory care of pneumothorax
- catheter in pleural space
- devices have a one-way valve and vent to prevent air and fluid return to the pleural space while allowing for controlled escape of air and drainage of fluid
- can be an outpatient
where to insert chest drain
- 5th intercostal space (or the inferior nipple line)
- Midaxillary line (or the lateral edge of the latissimus dorsi)
- Anterior axillary line (or the lateral edge of the pectoralis major)
insert ABOVE RIB to avoid neurovascular bundle
mx of persistent/recurrent pneumothorax
video-assisted thoracoscopic surgery (VATS)
fit to fly after pneumothorax
can travel 2 weeks after successful drainage
chest drain swinging in the right place sign
- water level rise on inspirations and falls on expiration
complications of chest drain
air leak
surgical emphysema
signs of tension pneumothorax
- Tracheal deviation away from the side of the pneumothorax
- Reduced air entry on the affected side
- Increased resonance to percussion on the affected side
- Tachycardia
- Hypotension
Mx of tension pneumothorax
Insert a large bore cannula into the second intercostal space in the midclavicular line.”
Can also do fourth or fifth intercostal space, anterior to the midaxillary line
Chest drain is definitive mx
what is bronchiectasis
permanent dilation of the bronchi
sputum collects–>chronic cough–>infection
causes of bronchiectasis
- Idiopathic
- Pneumonia
- Whooping cough
- Tuberculosis
- Alpha-1-antitrypsin deficiency
- Connective tissue disorders (e.g., rheumatoid arthritis)
- Cystic fibrosis
- Yellow nail syndrome
sx of bronchiectasis
- SOB
- chronic productive cough
- recurrent chest infection
- weight loss
signs of bronchiectasis on examination
- Sputum pot by the bedside
- Oxygen therapy (if needed)
- Weight loss (cachexia)
- Finger clubbing
- Signs of cor pulmonale
- Scattered crackles throughout the chest that change or clear with coughing
- Scattered wheezes and squeaks
most common organism in bronchiectasis
haemophilus influenza
pseudomonas aeruginosa
Xray findings in bronchiectasis
- tram track opacities
- ring shadows (dilated airways)
High res ST gold standard
mx of bronchiectasis
- pneumococcal + flu vax
- chest physio
- pulmonary rehab
- long term abx (azithromycin)
- inhaled colistin for pseudo
- long term oxygen
- surgical lung resection
- lung transplant
mx of infective exacerbation of bronchiectasis
- sputum culture
- abx 7-14 days
- ciprofloxacin if pseudomonas cause
Mx of atelectasis
chest physio and reposition
Conditions causing upper zone fibrosis
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation (usually 6-12 months post)
T - Tuberculosis
S - Silicosis/sarcoidosis
conditions causing lower zone fibrosis
A - asbestos.
C - connective tissue diseases (exc Ankylosing Spondylitis)
I - idiopathic pulmonary fibrosis.
D - drugs e.g. methotrexate, nitrofurantoin, bleomycin, amiodarone
when is bupropion contraindicated
PMH of seizures, lowers seizure threshold
conditions causing interstitial lung disease
inflammation and fibrosis of lung parenychma
- Idiopathic pulmonary fibrosis (the most important)
- Secondary pulmonary fibrosis
- Hypersensitivity pneumonitis
- Cryptogenic organising pneumonia
- Asbestosis
presentation if ILD
- SOB
- dry cough
- fatigue
examination findings of IPF
- bibasal fine end inspiratory crackles
- clubbing
- dry cough
- increasing SOB on exertion
- hypoxia
how to diagnose ILD
- clinical features
- HRCT
- spirometry (normal or restrictive)
mx of ILD
- poor prognosis
- oxygen
- treat cause
- stop smoking
- rehab
- vaccines
- advanced care planning
- lung transplant
what is IPF
PF with no cause
insidious onset >3months
>50y/o
2-5 yr life expectancy
medication to slow IPF
- pirfenidone
- nintedanib
Causes of secondary PF
- A1AD
- RA and SLE
- systemic sclerosis
- sarcoidosis
Drugs
- Amiodarone
- Cyclophosphamide
- Methotrexate
- Nitrofurantoin
what is hypersensitivity pneumonitis
type 3 and 4 hypersensitivity reaction
example of hypersensitivity pneumonitis
- Bird-fancier’s lung is a reaction to bird droppings
- Farmer’s lung is a reaction to mouldy spores in hay
- Mushroom worker’s lung is a reaction to specific mushroom antigens
- Malt worker’s lung is a reaction to mould on barley
What can asbestosis cause?
- lung fibrosis
- Pleural thickening and pleural plaques
- Adenocarcinoma
- Mesothelioma
what is a PE
thrombus in the pulmonary arteries
RFs for PE
- immobility
- recent surgery
- long haul flight
- pregnancy
- HRT w oestrogen, COCP
- malignancy
- polycythaemia
- thrombophilia
- SLE
VTE prophylaxis
LMWH
TED stockings
presentation of PE
- SOB
- Cough
- Haemoptysis
- Pleuritic chest pain
- Hypoxia
- Tachycardia
- Raised respiratory rate
- Low-grade fever
- Haemodynamic instability
- leg swelling
Wells score
probability of a patient having a PE
PERC rule
rules out PE
Diagnosing PE
Wells score
likely= CTPA or VQ
unlikely= D dimer, if positive then CTPA
Mx of PE
- O2, analgesia
- DOAC
- LMWH if DOAC unsuitable or eGFR<15
- massive PE= IV unfractionated heparin adn thrombolysis
Long term mx of PE
anticoag for 3 months if cause
6 months if no cause
3-6 months if active cancer
what is pulmonary hypertension
increased resistance and pressure in the pulmonary arteries
causes of pulmonary hypertension
- Group 1 – Idiopathic or connective tissue disease (e.g., systemic lupus erythematous)
- Group 2 – Left heart failure, usually due to MI or systemic hypertension
- Group 3 – Chronic lung disease (e.g., COPD or pulmonary fibrosis)
- Group 4 – Pulmonary vascular disease (e.g., pulmonary embolism)
- Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders
Mx of pulmonary hypertension
idiopathic- poor prognosis
- CCB, IV prostaglandin, sildenafil, endothelin receptor antagonists
secondary= treat cause
what is sarcoidosis
chronic granulomatous disorder
Granulomas= inflammatory nodules full of macrophages. The cause of these granulomas is unknown
can affect any organ
sarcoidosis demographic
- Aged 20-39 or around 60
- Women
- Black ethnic origin
signs of sarcoidosis
- resp sx
- erythema nodosum
- lymphadenopathy
- lupus pernio
- FLAWS
organs affects in sarcoidosis
- lungs: mediastinal lymphadenopathy, fibrosis, nodules
- eyes: uveitis, conjunctivitis, optic neuritis
- liver: nodules, cirrhosis, cholestasis
- heart: heart block
- kidney: stones, nephrocalcinosis, interstitial nephritis
- CNS: nodules, pituitary, encephalopathy
- PNS: facial nerve palsy
- Bones: arthralgia, aarthritis, myopathy
what is Lofgren’s syndrome
specific presentation of sarcoidosis. Triad:
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia
Ix for sarcoidosis
- Bloods: raised ACE and calcium
- CXR: hilar lymphadenopathy
Mx of sarcoidosis
conservative
- 1st line: steroids + bisphosphonates
- 2nd line: methotrexate
- lung transplant
prognosis of sarcoidosis
spontaneously resolves in 50%
others progresses to pulmonary fibrosis and hypertension
what is OSA
collapse of the pharyngeal airway
stop breathing
RF for OSA
- men
- middle age
- obesity
- alcohol
- smoking
presentation of OSA
- Episodes of apnoea
- Snoring
- Morning headache
- Waking up unrefreshed
- Daytime sleepiness
- Concentration problems
- Reduced O2 during sleep
- severe= HTN and HF
how to assess OSA
Epworth Sleepiness Scale
Sleep studies
Mx of OSA
- address reversible RFs
- CPAP
- mouth guard
- surgery: uvulopalatopharyngoplasty (UPPP)9
where is emphysema most prominent
lower lobes- A1AD
upper lobes- COPD
bupropion mechanism of action
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
varenicline mechanism of action
nicotinic receptor partial agonist
what is kartagener’s syndrome
primary ciliary dyskinesia
features:
- dextrocardia or complete situs inversus
- bronchiectasis
- recurrent sinusitis
- subfertility
demographic for adenocarcinoma
women and non-smokers
metastasise early
peripheral
gynaecomastia and hypertrophic pulmonary osteoarthropathy
demographic for SCC
central
smoker
M>F
late metastasis
what virus is covid-19
severe acute respiratory syndrome coronavirus 2
presentation of covid-19
ranging from a mild common cold-like illness, to a severe viral pneumonia leading to acute respiratory distress syndrome
- fever
- cough
- dyspnoea
- anosmia
complications of covid-19
multi-organ failure, septic shock, and VTE, long covid
Ix for covid-19
RT-PCR
rapid antigen testing (lateral flow)
O2
ABG
Mx for covid-19
isolating
self-limiting
dexamethasone
oxygen, antivirals
what is extrinsic allergic alveolitis
- hypersensitivity induced lung damage due to exposure to a variety of inhaled organic particles
- bird fanciers’ lung: avian proteins from bird droppings
- farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
- malt workers’ lung: Aspergillus clavatus
- mushroom workers’ lung: thermophilic actinomycetes*
- dry cough, SOB, clubbing, fever
- imaging: upper/mid-zone fibrosis
- Mx: avoid antigen + oral steroid
time to wait between inhaler doses
30 seconds
what is a flail chest
- serious consequence of multiple rib fractures that can occur following trauma
- impairs ventilation of the lung on the side of injury
- can cause tension pneumothorax
- mx: invasive ventilation and surgical fixation
Long term mechanical ventilation in trauma patients can result in …
tracheo-oesophageal fistula formation (abdominal distension associated with ventilation)
